Abstract
Background: Direct oral anticoagulant (DOAC) use is increasing worldwide. However, if not taken or prescribed correctly, DOACs have serious side effects. It is crucial that healthcare providers (HCPs) provide patients with accurate information and counselling around DOACs, to optimize safe and effective use.
Aims: To assess HCPs' knowledge about oral anticoagulant indication, dosing, storage, and administration.
Methods: An electronic survey was distributed to HCPs across Canada from June to July 2017, with 18 questions on oral anticoagulant practical use.
Results: A total of 73 responses were received: 27 (37%) from Hematologists, 4 (5.4%) from Thrombosis Medicine specialists, 17 (23.3%) from nurse practitioners, 17 (23.3%) from pharmacists, and 8 (11%) from residents and fellows in Hematology training programs across Canada. The median duration of practice was 7 years (range 0.5 to 41). The majority of respondents (64 of 73; 88%) worked in the outpatient setting. Only 18 (25%) of the respondents correctly identified all the approved indications for warfarin and 4 DOACs including dabigatran, rivaroxaban, apixaban, and edoxaban. Most of the respondents (54 of 73; 74%) correctly identified that DOACs are not approved for treatment of heparin induced thrombocytopenia, cerebral sinus venous thrombosis, or mechanical prosthetic valves. However, 11 (15%) cited one or more of the above indications incorrectly; 7 of 11 (9.5%) alarmingly chose mechanical prosthetic valves as an indication for DOACs. Most of the respondents (51 of 73; 70%) felt comfortable or very comfortable prescribing oral anticoagulants. When counselling patients, 69 (95%) discussed the indication and bleeding side effects, 62 (85%) discussed when/how to take the drug, and only 37 (51%) discussed adherence and administration strategies. About two thirds of the respondents (63%) knew that dabigatran should not be crushed, however only 38 (52%) knew that it should not be exposed to moisture. Forty-five of the respondents (62%) knew that higher dose rivaroxaban should be taken with food. While 45 (62%) correctly adjusted the dose of apixaban based on age, only 35 (48%) did the same for dabigatran. 80%, 77%, 70%, and 45% correctly adjusted rivaroxaban, apixaban, dabigatran, and edoxaban, respectively for renal function.
Conclusions: Although the majority of respondents expressed comfort with oral anticoagulants, there are important knowledge gaps around HCPs' practical understanding of oral anticoagulants, particularly in correctly identifying approved indications and counselling patients on adherence and administration. These knowledge gaps (e.g., inappropriate DOAC use in patients with mechanical valves) may lead to significant patient harm in the form of thrombosis or bleeding. Future research should focus on educational interventions to improve HCPs' knowledge around oral anticoagulants, with the goal of enhancing patient safety.
Figure 1. What do health care providers counsel patients about when prescribing oral anticoagulants?
No relevant conflicts of interest to declare.
